Evidence-Based Practices for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder. Notes

04/09/2012

  1. In these states, different agencies (such as the state mental health authority) are responsible for administering Medicaid benefits to specific populations and are unable to report services delivered to individuals in a uniform manner.

  2. An inability to accurately identify beneficiaries with simultaneous private coverage or who were enrolled in managed care could potentially bias estimates of EBP receipt downward in the state, as some portion of their service use is expected to be missing from the MAX claims files.

  3. There were only 217 beneficiaries with an equal number of claims for schizophrenia and bipolar disorder. These beneficiaries were excluded from the measures of any use, continuous use, and monitoring of evidence-based medications, but included in all other measures that had identical definitions for both disorders.

  4. We excluded Maryland from our measures of cardiovascular and diabetes screening and monitoring of lithium and anticonvulsants due to potential missing managed care encounter data in 2007 MAX data.

  5. Mehrotra et al. (2007) used a more restrictive method to identify physical health examinations than was used in this study, suggesting that we may have found even fewer beneficiaries who received a physical health examination had we used a more restrictive method to identify these visits. In addition, readers should be cautious to compare findings from studies that use survey data with those that use claims.

  6. Any psychosocial service includes most ambulatory mental health services provided to beneficiaries with mental illness, including all psychosocial EBPs as well as crisis services, case management, behavioral interventions or management, intensive day treatment programs, residential or day habilitation programs, partial hospitalization, collateral contacts or collateral therapy, psychiatric outpatient or clinic visits, and other unspecified services provided by mental health clinics, psychiatrists, psychologists, or other mental health providers. It excludes substance abuse treatment, services aimed at the mental retardation and developmentally disabled (MR/DD) or autistic population, medication administration or medication management, and evaluation or assessment services. Visits to psychiatrists and other mental health providers billed as physician visits were only counted as psychosocial services if the visit was coded with a procedure code indicating the delivery of an EBP or one of the psychosocial services mentioned above.

  7. Several other psychosocial services have some evidence base but either are not widely established practices or lack Medicaid billing codes.

  8. Due to data limitations, we excluded California from our calculation of psychosocial EBPs. In California, counties have substantial responsibility for administering Medicaid services. Most beneficiaries are enrolled in health maintenance organizations (HMOs), from which specialty mental health services are carved out into county-based “mental health plans” (MHPs). Counties are responsible for paying mental health providers directly and in return receive funding from the state Medicaid agency after submitting claims to the California Department of Mental Health (DMH). Services in the MHPs are delivered on an FFS basis, but counties may require MHP providers to bill using HCPCS/CPT codes, DMH Mode of Service/Service Function codes, or a unique set of county-specific codes. While counties are required to translate any DMH or unique county codes into HCPCS/CPT codes before submitting claims to DMH, in many cases the translated codes are not as specific as those used to bill mental health services in other states. For more information on California’s claims system for mental health services, see the “Mental Health Medi-Cal Billing Manual,” available at http://www.dmh.ca.gov/MedCCC/docs/Mental_Health_Medi-Cal_Billing_Manual_v1-0_07-17-08.pdf.

  9. The regression modeled the odds of high medication continuity among beneficiaries with schizophrenia who received antipsychotics as a function of the following independent variables: residence in a state with a prior authorization policy for antipsychotics, generic copayment amount of $0.50-1, $2, or $3 versus $0; branded copayment amounts of $1, $2, or $3 versus $0; percentage of SMHA funding spent on community-based services measured using a 10 point scale that corresponded to 0-100 percent of funding; beneficiary gender, age, race, or residence in a mental health provider shortage area; HMO enrollment; and the presence of comorbid substance abuse, cardiovascular disease, or diabetes, as indicated by relevant diagnosis and/or procedure codes. The random effects regression accounted for the clustering of observations/beneficiaries by state.

    Nevada was dropped from the regression because the majority of its beneficiaries are missing information on county residence (used to identify those living in mental health shortage areas) in the MAX data files. The regression included 91,338 beneficiaries in 21 states who had schizophrenia and had filled at least one prescription for an antipsychotic during the year.

  10. We modeled the odds of medication continuity separately for schizophrenia and bipolar disorder because the evidence-based medications for these disorders are different, and thus the Medicaid policies and practices that may influence medication continuity may differ between the groups. The regression modeled the odds of high medication continuity among beneficiaries with bipolar disorder who received an evidence-based medication as a function of the following independent variables: the number of prior authorization policies in a state; generic copayment amount of $.50-1, $2, or $3 versus $0; branded copayment amounts of $1, $2, or $3 versus $0; percentage of SMHA funding spent on community-based services measured using a 10 point scale that corresponded to 0-100 percent of funding; beneficiary gender, age, race, or residence in a mental health provider shortage area; HMO enrollment; and the presence of comorbid substance abuse, cardiovascular disease, or diabetes, as indicated by relevant diagnosis and/or procedure codes. The regression included a variable for the number of prior authorization policies in a state as opposed to modeling each prior authorization policy separately because we had few states that required prior authorization for anticonvulsants, and thus, a lack of statistical variation to generate a useful estimate.

    Nevada was dropped from the regression because the majority of its beneficiaries are missing information on county residence (used to identify those living in mental health shortage areas) in the MAX data files. Alaska, North Dakota, South Dakota, and Wyoming were dropped from the regression because each state had fewer than 100 beneficiaries with valid values for the medication continuity measure. The regression included 33,124 beneficiaries across 17 states who had bipolar disorder and had filled at least one prescription for an evidence-based medication during the year.

  11. Beneficiaries enrolled in managed care were excluded from the calculation of average Medicaid costs for the study population, as we have incomplete data on payments made to managed care programs for their care. The average per beneficiary spending for all states is for fiscal year 2008 is drawn from Kaiser State Health Facts, available at http://statehealthfacts.org/comparemaptable.jsp?ind=183&cat=4.

  12. States are not supposed to submit claims for services funded by state-only dollars in the data files used to create the MAX data files. The IMD exclusion prohibits federal Medicaid matching funds for services delivered to working-age adults in IMDs, which generally include psychiatric hospitals. As a result, stays in a psychiatric hospital among working-age adults cannot generally be observed in the MAX data.

  13. These services include RXs, psychosocial rehabilitation services such as ACT or counseling, and some laboratory tests and routine physical health screenings. Further details on the EBPs measured in the analysis are in Chapter IV.

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